PREDICTIVE FACTORS OF SURGICAL SUCCESS WITH THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE.

PURPOSE: To present new morphologic features correlating with functional and anatomical outcomes of the inverted internal limiting membrane flap technique in full-thickness macular hole. METHODS: A retrospective study of 51 successful and 22 failed full-thickness macular hole surgeries. In all eyes, preoperative spectral domain optical coherence tomography (SD-OCT) or swept source optical coherence tomography (SS-OCT) were reviewed. The presence of supraretinal pigment epithelium granular deposits, presence of an epiretinal membrane or epiretinal proliferation, visibility of posterior hyaloid, continuity of the interdigitation zone or external limiting membrane, presence of cystoid spaces, irregular surface of the margins of full-thickness macular hole, visibility of the suprachoroidal space, and diameters of full-thickness macular hole were analyzed. RESULTS: In multivariate analysis, the success of the first surgery depended solely on the absence of epiretinal membrane ( P < 0.05).In univariate analysis, the success of the first surgery was correlated moreover with the absence of preoperative supraretinal pigment epithelium granular deposits ( P = 0.0010), the absence of an epiretinal proliferation ( P = 0.0060), and the absence of an irregular border of the hole ( P = 0.010). CONCLUSION: In multivariate analysis, epiretinal membranes were a negative prognostic factor for macular hole closure when the inverted internal limiting membrane flap technique was used. Worse final visual acuity was observed in patients with primary anatomical failure, even if the hole was successfully closed during the second intervention.

Fundus Autofluorescence Patterns in Subretinal Hemorrhages Associated with Neovascular Age-Related Macular Degeneration.

INTRODUCTION: Submacular hemorrhage (SMH) is a vision-threatening complication of neovascular age-related macular degeneration (AMD). The exact treatment scheme is not established yet. The aim of the current study was to describe surgical results and fundus autofluorescence (FAF) patterns after pars plana vitrectomy (ppV) + subretinal tissue plasminogen activator (tPA) + anti-vascular endothelial growth factor (VEGF) and intravitreal tPA + anti-VEGF + sulfur hexafluoride (SF6) tamponade and to compare them to intravitreal tPA + anti-VEGF + SF6 in the treatment of SMH in the course of AMD. MATERIALS AND METHODS: We performed FAF imaging in patients with a previous SMH in the course of AMD with a duration of <60 days treated with vitrectomy with subretinal anti-VEGF and tPA and intravitreal anti-VEGF, tPA, and SF6 administration (group 1) or intravitreal tPA + anti-VEGF + SF6 (group 2). In all eyes, a throughout ophthalmic examination, fluorescein angiography, and spectral domain optical coherence tomography (SD-OCT) were done for diagnosis. SD-OCT was performed monthly during treatment. RESULTS: Three FAF patterns were observed in both groups. Pattern one (normal autofluorescence) was observed in 5/18 in group one and 5/21 group two. Pattern two was observed in 6/18 in group one and 7/21 in group two. Pattern three was noted in 7/18 in group one and 5/21 in group two. Improvement in visual acuity was statistically significant for both groups: 0.01 Snellen (2.0 logMAR) to 0.11 Snellen (0.96 logMAR) in group one (p = 0.019) and 0.11 Snellen (0.96 logMAR) to 0.33 Snellen (0.48 logMAR) in group two (p = 0.0007). Central retinal thickness also decreased with statistical significance for both groups (p < 0.05). CONCLUSION: FAF patterns did not depend on the treatment used, but solely on the duration of SMH before treatment. SMH if not treated prompt enough might cause long-standing photoreceptor and retinal pigment epithelium defect, which is represented by hypo- and hyperautofluorescence. Performing a subretinal injection of tPA and anti-VEGF does not cause any defects associated with the injection site. That might be associated with previous local internal limiting membrane peeling, which reduces the injection pressure. Not only prompt treatment of SMH but also further continuation of anti-VEGF treatment is mandatory to maintain vision.

Vitrectomy with ILM peeling in diabetic macular edema in one eye vs. intravitreal anti-VEGF injections in the second eye: a comparative study.

PURPOSE: The aim of this study was to compare the results of vitrectomy performed in patients' worse eyes with diabetic macular edema to the results of continuous anti-VEGF treatment performed in patients' fellow eyes. METHODS: A retrospective interventional study of 14 patients with diabetic macular edema in both eyes. The better eye was always qualified for aflibercept injections (group 1), and the worse eye was scheduled for vitrectomy (group 2). The follow-up lasted 12 months. The following parameters were measured: visual acuity (V), central retinal thickness (CRT), maximum retinal thickness (MRT), central choroidal thickness (CCT), superficial fovea avascular zone (sFAZ) and deep fovea avascular zone (dFAZ), and vessel density at the level of superficial (sVD) and deep (dVD) retinal vessels. RESULTS: None of the analyzed factors differed between groups with statistical significance at any timepoint. The time of recovery of vision was identical in both eyes (F = 0.91, p = 0.449). The final sFAZ was significantly smaller for group 2 (median 196 µm) than for group 1 (median 375 µm; U = 101.0; p = 0.022; r = 0.44). CONCLUSION: Both techniques resulted in similar improvements in visual acuity and decreases in CRT after 1 year. sFAZ decreased in all eyes, with a higher extent after vitrectomy.

Spontaneous Closure of Full-Thickness Macular Holes.

PURPOSE: To describe retinal morphology and vision recovery after spontaneous closure of full-thickness macular hole (FTMH). MATERIALS AND METHODS: Retrospective, observational study. From a database containing 750 FTMH, we included 23 cases. All patients had a complete ophthalmic examination. Swept-source optical coherence tomography angiography was performed. RESULTS: Prior to spontaneous closure in 11 women and 12 men (mean age 67 years), the mean minimum FTMH diameter was 201 µm, and mean base FTMH diameter was 638 µm. Visual acuity improved from 0.29 Snellen to 0.47 Snellen (p = 0.001) after 6 months and showed no further improvement. Spontaneous closure of FTMH was associated with vitreous detachment in less than half of the cases. Irregularities in the deep vascular layer and hyporeflective areas in the choriocapillaris were noted. DISCUSSION: Equal sex distribution of spontaneous closures (1:1) differs from the high prevalence of females seen in the literature. Complete visual recovery is uncommon in cases of spontaneous closure of FTMH. It might be explained by prolonged defects of the choriocapillaris layer. These findings, along with the evolution of the various morphologies reported in the study, could possibly suggest that delaying vitrectomy while hoping for spontaneous closure might not be justified.

UNDERDIAGNOSED OPTIC DISK PIT MACULOPATHY: Spectral Domain Optical Coherence Tomography Features For Accurate Diagnosis.

PURPOSE: To report a cohort with optic disk pit maculopathy (ODPM) presenting with neurosensory macular detachment that were initially misdiagnosed and mistreated; and to describe structural features on spectral domain optical coherence tomography in misdiagnosed and all other consecutive cases of ODPM. METHODS: Multicenter international retrospective cohort study. PARTICIPANTS: 59 eyes from 59 patients with ODPM. MAIN OUTCOME MEASURES: 1) Proportion of patients with ODPM initially misdiagnosed, inaccurate diagnosis and treatment. 2) Morphologic features on spectral domain optical coherence tomography: other causes of subretinal and/or intraretinal fluid, inner/outer retinoschisis, communication with optic disk pit, and retinal pigment epithelium alterations. 3) Visual and anatomical outcomes 6 months after proper treatment. RESULTS: Fifteen patients (25.4%) with ODPM were correctly diagnosed initially and those were significantly younger than misdiagnosed cases (age 33.8 ± 15.2 vs. 58.7 ± 15.8 years, P < 0.0001). Forty of forty-four misdiagnosed eyes (90.9%) were treated for their presumed diagnosis before referral. Eyes with initial misdiagnosis had significantly more outer retinoschisis at baseline (88.4 vs. 40.0%, P = 0.0002) and more retinal pigment epithelium alterations (90.0 vs. 27.3%, P < 0.0001) 6 months after proper treatment. CONCLUSION: Optic disk pit maculopathy is an underdiagnosed entity and can mimic other causes for subretinal fluid. Awareness and identification of pertinent spectral domain optical coherence tomography features can help avoid inappropriate and delayed treatment.

SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY REVEALS INTERNAL LIMITING MEMBRANE PEELING ALTERS DEEP RETINAL VASCULATURE.

PURPOSE: To describe morphology of retinal and choroidal vessels in swept-source optical coherence tomography angiography before and after vitrectomy with the temporal inverted internal limiting membrane (ILM) flap technique for full-thickness macular holes. METHODS: Prospective, observational study of 36 eyes of 33 patients with full-thickness macular holes swept-source optical coherence tomography angiography was performed in patients before and 1 month after vitrectomy. Vitrectomy with the temporal inverted ILM flap technique was performed. In this method, ILM is peeled only at one side of the fovea. An ILM flap is created to cover the macular hole. Comparison of retina vasculature in the areas of ILM peeling vs. no ILM peeling at 1 and 3 months after successful vitrectomy was performed. RESULTS: The study demonstrated lower density of vessels in the deep retinal plexus in the area where ILM was peeled as compared to the rest of the fovea. Visual acuity and central retinal thickness 1 month after surgery correlates with fovea avascular zone diameter in deep retinal layers at the same time point (P = 0.001). CONCLUSION: This study confirmed that ILM peeling might alter blood flow in deep retinal vessels below the peeling area in the early postoperative period. The area of the fovea avascular zone corresponds to functional results at the same time point.

MECHANISM OF "FLAP CLOSURE" AFTER THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE.

PURPOSE: Recent studies described that in approximately 14% to 16% of cases of macular holes treated with the inverted internal limiting membrane flap technique, the hole was closed only by a thin layer of inverted internal limiting membrane-"flap closure." The aim of this article was to describe the functional and anatomical results in flap closure macular holes and also the mechanism of flap closure. METHODS: A retrospective observational study of 149 eyes of 139 patients treated with vitrectomy using the inverted internal limiting membrane flap technique was reviewed to aggregate eyes with flap closure. Complete ophthalmic examination was performed preoperatively and at 7 days, 1, 3, 6, and 12 months after surgery. RESULTS: Flap closure (Group 1) was noted in 24 eyes and other closure types in 125 eyes (Group 2). The mean minimal and base diameters of the macular holes in the flap closure group were greater than those in Group 2 (P < 0.001). The mean postoperative best-corrected visual acuity in the flap closure group (20/100) was lower than that in Group 2 (20/50) (P < 0.001). CONCLUSION: Flap closure probably enables closure of large macular holes with a higher probability of remaining open without the use of the inverted internal limiting membrane flap technique. Foveal architecture continuously improved.

Optical low-coherence reflectometry in the calculation of intraocular lens power in silicone oil-filled eyes.

PURPOSE: To evaluate the refractive outcome after combined surgery of silicone oil removal with phacoemulsification and intraocular lens implantation. We calculated ocular lens implantation power with optical low-coherence reflectometry (Lenstar LS900; Haag Streit, Koniz, Switzerland) in silicone oil-filled eyes. METHODS: Prospective, comparative study. The intraocular lens power of 35 silicone oil-filled eyes of 35 patients was calculated with a Lenstar LS900 laser biometer. In all cases we performed a combined procedure of pars plana vitrectomy with silicone oil removal and phacoemulsification with intraocular lens implantation. We analyzed the spherical equivalent of predicted and postoperative refractive error. A control group consisted of 25 cases of cataract extraction and intraocular lens implantation in non-vitrectomized eyes. RESULTS: The mean deviation of the final refraction was -0.03 ± 1.06 diopters and did not differ significantly from non-vitrectomized eyes (P < 0.05). 68.6% eyes had a deviation of ±1 diopter. There were no differences between high myopic and emmetropic silicone oil-filled eyes (-0.05 ±1.33 diopters vs. -0.03 ± 1.00 diopters; P < 0.05). CONCLUSIONS: Optical low-coherence reflectometry enables accurate intraocular lens power calculations in silicone oil-filled eyes. The refractive outcome is as accurate as in non-vitrectomized eyes.

The analysis of macular thickness asymmetry in primary open angle glaucoma using Spectral- -Domain Optical Coherence Tomography.

PURPOSE: To analyze central retinal thickness asymmetry in patients with known and suspected primary open angle glaucoma. MATERIAL AND METHODS: A prospective analysis of 21 patients with known glaucoma and 53 patients with suspected glaucoma. A control group consisted of 25 healthy volunteers. Each enrolled patient had a spectral domain optical coherence tomography performed including a circumpapillary retinal nerve fiber layer and central retinal thickness measurements. A central 20 degree area was divided into 64 3° x 3° areas. The mean retinal thickness was measured in each small square and the value obtained in the upper half of every square was compared to the corresponding value in the lower half. A correlation between the mean circumpapillary retinal nerve fiber layer thickness and the central retinal thickness was assessed. RESULTS: The mean thickness of circumpapillary retinal nerve fiber layer was significantly lower in patients with known and suspected glaucoma (92.15 ±12.85 µm; 93.84 ± 11.45 µm vs. 97.82 ± 7.48 µm; P<0.05). The mean central retinal thickness did not differ significantly between the groups (291.05 ± 15.86 µm; 290.46 ± 13.60 µm vs. 293.94 ± 11.07 µm; P>0.05). Macular asymmetry was detected significantly more frequently in glaucomatous and glaucoma suspected eyes (78%; 66% vs. 32%; P<0.05). An association between the measured values was observed. CONCLUSIONS: The macular thickness measurements and macular asymmetry analysis may represent a novel strategy in glaucoma diagnosis.

Idiopathic uveal effusion syndrome - case report.

The idiopathic uveal effusion syndrome is a rare disease characterized by serous choroidal detachment. The pathogenesis of idiopathic effusion syndrome has not been conclusively determined yet. One hypothesis postulates compression of the vortex veins and abnormal diffusion of extravascular proteins. A possible complication of the disease is retinal detachment. We present a case of 59-year-old woman with idiopathic uveal effusion in the left eye. The uncorrected visual acuity was 5/5 in both eyes. Ultrasonography, ultrasound biomicroscopy, spectral optical coherence tomography and magnetic resonance imaging were performed, which excluded secondary causes of the disease. Spontaneous resolution was observed over a two-week period, without the recurrence in one-year follow up. The diagnosis was based on the clinical exam findings. The uveal effusion syndrome may be idiopathic, although in the majority of patients it is secondary to other ocular conditions, such as hypotony or inflammation.

Choroidal morphology and the outer choroidoscleral boundary in dry age related maculopathy in Swept Source Optical Coherence Tomography. / [Ocena morfologii naczyniówki oraz granicy naczyniówkowo-twardówkowej za pomoca optycznej koherentnej tomografii z uzyciem lasera strojonego u chorych na sucha postac zwyrodnienia plamki zwiazanego z wiekiem].

Background and objective: To report on details of the choroid in dry age-related macular degeneration imaged with Swept Source Optical Coherence Tomography. Material and methods: Swept Source Optical Coherence Tomography was performed in 28 eyes with dry age-related macular degeneration (Group 1), who were age and refractive error-matched with 28 eyes of 28 healthy controls (Group 2). The visibility and contour of the outer choroidoscleral boundary and suprachoroidal layer was estimated. Results: Choroidoscleral boundary was visible in all eyes, irregular in 78% in Group 1 and in 18% in Group 2. Suprachoroidal layer was visible in 36% eyes in Group 1 and in 7% eyes in Group 2. Mean choroidal thickness did not differ between groups (p=.11). Conclusions: The outer choroidoscleral boundary is irregular in most cases of age-related macular degeneration. Suprachoroidal layer and suprachoroidal space are more often visible in dry age-related macular degeneration than in healthy controls.

The outer choroidoscleral boundary in full-thickness macular holes before and after surgery-a swept-source OCT study.

PURPOSE: To report on choroidal thickness and the morphology of the outer choroidoscleral boundary in swept-source OCT in patients with full-thickness macular holes (FTMH) before and after surgery. METHODS: Single center matched case-control study of 32 patients with FTMH (group 1), fellow eyes (group 2), and 32 eyes of 32 healthy controls (group 3). All eyes from group 1 had vitrectomy with a minimum follow-up of 3 months. Main outcome measures were the visibility and regularity of the outer choroidoscleral boundary (CSB), and additionally the eventual visibility of the suprachoroidal layer (SCL). RESULTS: Choroidal thickness was indifferent between groups. Choroidal thickness did not change after surgery (p = 0.1). CSB was visible in all cases. CSB was irregular in 59 % of eyes in group 1, in 40 % of eyes in group 2, and in any eye in group 3. SCL was visible in 34 % of eyes in group 1, and remained visible after surgery. In group 2, SCL was observed in 44 % of eyes, and in group 3 in one eye. CONCLUSIONS: Choroidal thickness does not differ between eyes with FTMH and their fellow eyes and healthy controls. CSB is more often irregular and SCL is more often visible in eyes with FTMH and their fellow eyes than in healthy controls. In fellow eyes of FTMH, the visibility of SCL was observed more often in eyes with partial vitreous detachment (p = 0.0). Three months after surgery, choroidal thickness does not change, the irregularities of CSB and SCL remain visible. More frequent changes of the outer choroidoscleral boundary in FTMH, and especially in their fellow eyes, may suggest a role of the choroid in the pathogenesis of FTMH.

TEMPORAL INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS CLASSIC INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE: A Comparative Study.

PURPOSE: To determine if reducing the area of internal limiting membrane (ILM) peeling in the inverted ILM flap technique results in satisfactory outcomes for the repair of large Stage IV idiopathic macular holes. METHODS: Prospective comparative interventional study of 87 consecutive eyes. Participants were randomized into two treatment groups. In Group A, the classic inverted ILM flap technique was performed. In Group B, a modification of this procedure, the temporal inverted ILM flap technique, was performed. In the modified inverted ILM flap technique, peeling of the ILM was restricted to the temporal side of the fovea only--the macular hole was then covered with the temporal ILM flap. RESULTS: There was no significant difference in initial and final visual acuities between Groups A and B. In both groups, defects in photoreceptors and the external limiting membrane decreased with time. Successive postoperative examinations revealed an increasing number of patients with the dissociated optic nerve fiber layer appearance, although this was less frequent in Group B (modified ILM flap) than in Group A. CONCLUSION: The study results indicate that the temporal inverted ILM flap technique is as effective as the classic inverted ILM flap technique for the repair of large Stage IV macular holes.

Choroidal thickness measured with swept source optical coherence tomography before and after vitrectomy with internal limiting membrane peeling for idiopathic epiretinal membranes.

PURPOSE: In eyes with epiretinal membranes (ERMs), retinal arteries become dilated and tortuous. This may correlate with the hemodynamics of the affected areas and possibly with choroidal thickness. The aim of this study was to estimate choroidal thickness before and after vitrectomy for idiopathic ERM in the operated eye and in the unaffected fellow eye. METHODS: A prospective study of 21 patients with idiopathic ERMs. We obtained swept source optical coherence tomography images that simultaneously evaluated the vitreous, retina, and choroid. We performed choroidal thickness measurements before pars plana vitrectomy with ERM removal and internal limiting membrane peeling. We took subsequent images 10 days and then 3 months after surgery. We compared the images with patients' fellow eyes. In each eye, we performed 256 horizontal scans, 12 mm in length and centered on the fovea. We manually calculated choroidal thickness from the posterior edge of the retinal pigment epithelium to the choroidoscleral boundary with the built-in caliper and additionally measured it automatically using DRI-OCT mapping software. We evaluated the outer choroidoscleral boundary and performed statistical analysis. RESULTS: We observed an ERM in 50% of fellow eyes. Mean choroidal thickness did not differ between study and fellow eyes (P = 0.67). Choroidal thickness decreased from 200 µm to 173 µm (P = 0.034) 3 months after vitrectomy and internal limiting membrane peeling. In all but two cases, the outer choroidoscleral boundary was irregular. Additionally, we observed that the suprachoroidal layer consists of two bands in four cases, an inner hyperreflective band and an outer hyporeflective one. We speculate the latter correlates with the suprachoroidal space. CONCLUSION: Normalization of choroidal thickness after surgery suggests that there is some relationship between choroidal thickness and structure and the presence of idiopathic ERMs.

Suprachoroidal layer and suprachoroidal space delineating the outer margin of the choroid in swept-source optical coherence tomography.

PURPOSE: To define the morphology of outer choroidal margins in swept-source optical coherence tomography. METHODS: This is a prospective observational study of 180 eyes: 20 eyes of healthy volunteers, 20 eyes of myopic patients, and 20 eyes from each of the following groups: macular hole, lamellar macular hole, epiretinal membranes, drusen, dry age-related macular degeneration (AMD), neovascular AMD, and vitreomacular traction. A single 12-mm wide swept-source optical coherence tomography image for each of the examined eyes consisting of 1,024 A-scans has been created. The main outcome measure selected was to estimate the presence of suprachoroidal layer, as well as to estimate the ability to delineate the outer choroidoscleral boundary using the software available (DRI-OCT) and to determine its shape. RESULTS: Suprachoroidal layer was observed in 5% of healthy emmetropic eyes, in 50% of eyes with full-thickness macular holes, and in 60% of eyes with vitreomacular traction syndrome. It was also present in 50% of eyes with dry AMD and in 20% of eyes with neovascular AMD. The outer margin of the choroid in all eyes of the healthy volunteers and in eyes with macular diseases has been delineated correctly. In all healthy and myopic eyes, we recognized the outer choroidoscleral boundary as having a regular shape following the natural oval contour of the globe. In eyes with epiretinal membranes, macular hole, vitreomacular traction, and AMD, the outer choroidoscleral boundary was irregular; the choroid varied in thickness from point to point. CONCLUSION: Swept-source optical coherence tomography enables exact visualization of the outer choroidoscleral boundary. Suprachoroidal layer consisting of two bands has been recognized, the upper of which is hyperreflective and the lower of which is hyporeflective. It may be supposed that the lower hyporeflective band corresponds to suprachoroidal space, which was not earlier visualized in vivo in eyes without choroidal effusion. Suprachoroidal layer in myopic and emmetropic healthy subjects has been rarely observed. We observed it more frequently in different macular diseases.

Rhegmatogenous retinal detachment coexisting with a full-thickness macular hole.

To present an uncommon case of coexistent rhegmatogenous retinal detachment and full-thickness macular hole, documented with Spectral Domain Optical Coherence Tomography, which closed after scieral buckling surgery. A 76-year-old woman presented with rhegmatogenous retinal detachment, with a primary peripheral tear. The coexistence of full-thickness macular hole was confirmed with Spectral Domain Optical Coherence Tomography. The best corrected visual acuity was counting fingers. Scleral buckling surgery with gas injection was performed. This single procedure not only resulted in retinal attachment but also enabled closure of the macular hole. After 14 weeks, the retina remained reattached and the Spectral Domain Optical Coheren- ce Tomography scans revealed closure of the macular hole. The final best corrected visual acuity improved to 0.5. Rhegmatogenous retinal detachment coexisting with a full-thickness macular hole is uncommon. This case demonstrates that in such rare situations it is worth beginning the treatment process with scleral buckling in order to close all peripheral tears. We may hypothesize that gliosis--the result of healing processes after retinal detachment--might have been the primary mechanism responsible for the idiopathic full-thickness macular hole closure in this particular case. Nevertheless, the actual mechanism still remains unknown.

Inverted internal limiting membrane flap technique for surgical repair of myopic macular holes.

PURPOSE: To present the anatomical and functional results of vitrectomy with the "inverted internal limiting membrane flap technique" in myopic macular holes without retinal detachment. METHODS: A prospective interventional study of 19 myopic eyes with a spherical equivalent >-6 diopters with macular holes in 18 consecutive patients. Preoperative and postoperative visual acuity and spectral domain optical coherence tomography images were evaluated. The main outcome measure was visual outcome and macular hole closure rate. RESULTS: Mean visual acuity improved from 1.2 logMAR to 0.56 logMAR. We confirmed the closure of the macular hole with spectral domain optical coherence tomography in all cases. The closure of the macular hole began in the inner retinal layers, and the architecture gradually filled with tissue. Photoreceptor and external limiting membrane defects improved during the first 12 months after surgery. CONCLUSION: Vitrectomy with the inverted internal limiting membrane flap technique may be an effective addition to surgical options for treating myopic macular holes. Spectral domain optical coherence tomography images confirm that the process of foveal architectural repair after this surgery continues over at least a 12-month period.